Child's Last Name

Child's First Name and Middle Initial

Home Address/City/ZIP

Home Phone

Parent/Guardian Email

Date of Birth

Sex SexFemaleMale

Grade

School

Requested Start Date (if different from the first day of school)

Kindergarten Extended Day (KED) - First come, first serve enrollment, with limited spaces available. Please check before and after school options if those additional hours are needed. Kindergarten Extended Day (KED) - First come, first serve enrollment, with limited spaces available. Please check before and after school options if those additional hours are needed. Monday Tuesday Wednesday Thursday Friday Per Diem (occasional use only)

Before School (7:30-8:30 am) Before School (7:30-8:30 am) Monday Tuesday Wednesday Thursday Friday Per Diem (occasional use only)

After School (3:15-6:00pm) After School (3:15-6:00pm) Monday Tuesday Wednesday Thursday Friday Per Diem (occasional use only)

About Your Child - To help us provide the most appropriate care and supervision for your child, please inform us as to whether your child have any special needs (ex. physical, emotional or developmental) which may require accommodation by our program. If so, please detail those needs and consider providing MSCCOS authorization to discuss with the child's teacher, Haddonfield Child Study Team, and principal as necessary.

I give authorization for MSCCOS to discuss my child's needs with Haddonfield School and Child Study Team personnel. I give authorization for MSCCOS to discuss my child's needs with Haddonfield School and Child Study Team personnel. Yes No

Parent/Guardian Signature (type your name)

Date